Method and apparatus for fixation of an ACL graft

ABSTRACT

A system for use in graft fixation in a knee reconstruction procedure can include a first femoral fixation member adapted to be retained relative to a first end of a femoral tunnel and a first self-locking adjustable flexible member construct having a passage portion with a pair of free ends and a pair of self-locking adjustable loops. The first flexible member construct can be interconnected to the first femoral fixation member. A second femoral fixation member can be coupled to the first flexible member construct and can be adapted to be positioned in the femoral tunnel relative to a second end of the femoral tunnel adjacent a joint space between the femur and a tibia. A second self-locking adjustable flexible member construct having a passage portion with a pair of free ends and a pair of self-locking adjustable loops can be interconnected to the second femoral fixation member.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is related to U.S. patent application Ser. No.13/109,667, entitled “Method and Apparatus for Fixation of an ACL Graft”and filed May 17, 2011 and incorporated by reference herein.

This application is a continuation of U.S. patent application Ser. No.14/635,055 filed on Mar. 2, 2015, now U.S. Pat. No. 10,004,588 whichissued on Jun. 26, 2018, which is a divisional of U.S. patentapplication Ser. No. 13/109,672 filed on May 17, 2011, now U.S. Pat. No.8,968,364 which issued on Mar. 3, 2015, which is a continuation-in-partof U.S. patent application Ser. No. 12/938,902 filed on Nov. 3, 2010,which is now U.S. Pat. No. 8,597,327 issued on Dec. 3, 2013, which is acontinuation-in-part of U.S. patent application Ser. No. 12/915,962filed on Oct. 29, 2010, which is now U.S. Pat. No. 8,562,647 issued onOct. 22, 2013, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/719,337 filed on Mar. 8, 2010, now U.S. Pat. No.9,078,644 which issued on Jul. 14, 2015, which is a continuation-in-partof U.S. patent application Ser. No. 12/489,168 filed on Jun. 22, 2009,which is now U.S. Pat. No. 8,361,113 issued on Jan. 29, 2013, which is acontinuation-in-part of United. States patent application Ser. No.12/474,802 filed on May, 29, 2009, which is now U.S. Pat. No. 8,088,130issued on Jan. 3, 2012, which is a continuation-in-part of (a) U.S.patent application Ser. No. 12/196,405 filed on Aug. 22, 2008; which isnow U.S. Pat. No. 8,128,658 issued on Mar. 6, 2012; (b) U.S. patentapplication Ser. No. 12/196,407 filed on Aug. 22, 2008, which is nowU.S. Pat. No. 8,137,382 issued on Mar. 20, 2012; (c) U.S. patentapplication Ser. No. 12/196,410 filed on Aug. 22, 2008, which is nowU.S. Pat. No. 8,118,836 issued on Feb. 21, 2012; and (d) acontinuation-in-part of U.S. patent application Ser. No. 11/541,506filed on Sep. 29, 2006, which is now U.S. Pat. No. 7,601,165 issued onOct. 13, 2009.

This application is a divisional of U.S. patent application Ser. No.13/109,672, filed on May 17, 2011, now U.S. Pat. No. 8,968,364 whichissued on Mar. 3, 2015, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/570,854 filed on Sep. 30, 2009, which is nowU.S. Pat. No. 8,303,604 issued on Nov. 6, 2012, which is acontinuation-in-part of U.S. patent application Ser. No. 12/014,399filed on Jan. 15, 2008, which is now U.S. Pat. No. 7,909,851 issued onMar. 22, 2011, which is a continuation-in-part of U.S. patentapplication Ser. No. 11/347,661 filed on Feb. 3, 2006, which know U.S.Pat. No. 7,749,250 issued on Jul. 6, 2010.

This application is a divisional of U.S. patent application Ser. No.13/109,672 filed on May 17, 2011, now U.S. Pat. No. 8,968,364 whichissued on Mar. 3, 2015, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/702,067 filed on Feb. 8, 2010, which is now U.S.Pat. No. 8,672,968 issued on Jun. 10, 2010, which is a continuation ofU.S. patent application Ser. No. 11/541,505 filed on Sep. 29, 2006 andis now U.S. Pat. No. 7,658,751 issued on Feb. 9, 2010.

This application is a divisional of U.S. patent application Ser. No.13/109,672 filed on May 17, 2011, now U.S. Pat. No. 8,968,364 whichissued on Mar. 3, 2015, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/196,398 filed Aug. 22, 2008, which is now U.S.Pat. No. 7,959,650 issued on Jun. 14, 2011, which is acontinuation-in-part of U.S. patent application Ser. No. 11/784,821filed Apr. 10, 2007, now U.S. Pat. No. 9,017,381 which issued on Apr.28, 2015.

The disclosures of all of the above applications are incorporated byreference herein.

FIELD

The present disclosure relates generally to a method and apparatus forfixation of an anterior cruciate ligament (ACL) graft.

BACKGROUND

This section provides background information related to the presentdisclosure that is not necessarily prior art.

Ligaments are strong fibrous connective soft tissue that connect thearticular ends of bones to bind them together and to facilitate or limitmotion. Injuries to ligaments are common, and patients who arephysically active are generally more susceptible to such ligamentinjuries.

The anterior cruciate ligament (ACL) of the knee joint is a ligamentfrequently injured by such patients. Such injuries cause instability inthe knee joint which, when left untreated, may lead to degenerativearthritis. Because of this condition, ACL reconstruction may berequired. Generally during ACL reconstruction, a substitute soft tissueligament or graft is attached to the femur and/or tibia to facilitateregrowth and permanent attachment. The substitute graft can include oneor more graft bundles or strands that are tensioned prior to the femoraland/or tibial fixation.

SUMMARY

This section provides a general summary of the disclosure, and is not acomprehensive disclosure of its full scope or all of its features.

In one form, a system for use in graft fixation in a knee reconstructionprocedure is provided in accordance with various aspects of the presentteachings. The system can include a first femoral fixation memberadapted to be retained relative to a first end of a femoral tunnel in afemur and a first self-locking adjustable flexible member constructhaving a first passage portion with a first pair of free ends and afirst pair of self-locking adjustable loops. The first flexible memberconstruct can be interconnected to the first femoral fixation member. Asecond femoral fixation member can be coupled to the first flexiblemember construct and can be adapted to be positioned within the femoraltunnel relative to a second end of the femoral tunnel adjacent to ajoint space between the femur and a tibia. A second self-lockingadjustable flexible member construct having a second passage portionwith a second pair of free ends and a second pair of self-lockingadjustable loops can be interconnected to the second femoral fixationmember.

In another form, a method of graft fixation for use in a kneereconstruction procedure is provided in accordance with various aspectsof the present teachings. The method can include forming a femoraltunnel in a femur and a tibial tunnel in a tibia, where the femoraltunnel includes a first end adjacent to a joint space between the femurand the tibia and the tibial tunnel includes a first end adjacent to thejoint space and an opposite second end spaced apart from the jointspace. A first femoral fixation member coupled to a first self-lockingadjustable flexible member construct can be positioned into the femoraltunnel and the first femoral fixation member can be retained relative tothe femoral tunnel, where the first flexible member construct caninclude a first pair of adjustable loops. The free ends of the firstflexible member construct can be tensioned to reduce a size of the firstpair of adjustable loops and draw the graft into the femoral tunnel. Thegraft can be passed through the tibial tunnel and can be tensionedrelative to the femoral and tibial tunnels. A fixation member can beimplanted relative to the tibial tunnel to fix the tensioned graft tothe tibia. A second femoral fixation member can be implanted in thefemoral tunnel such that a distal end of the second femoral fixationmember is positioned adjacent the first end of the femoral tunnel to fixthe graft relative to the first end of the femoral tunnel.

In yet another form, a method of graft fixation for use in a kneereconstruction procedure is provided in accordance with various aspectsof the present teachings. The method can include forming a femoraltunnel in a femur and a tibial tunnel in a tibia, where the femoraltunnel includes a first end adjacent to a joint space between the femurand the tibia and the tibial tunnel includes a first end adjacent to thejoint space and an opposite second end spaced apart from the jointspace. A first femoral fixation member coupled to a first self-lockingadjustable flexible member construct can be positioned into the femoraltunnel and the first femoral fixation member can be retained relative tothe femoral tunnel, where the first flexible member construct caninclude a first pair of adjustable loops. The graft can be coupled tothe first pair of adjustable loops of the first flexible memberconstruct. The free ends of the first flexible member construct can betensioned to reduce a size of the first pair of adjustable loops anddraw the graft and a portion of a second flexible member constructcoupled to the first flexible member construct into the femoral tunnel,where the second flexible member construct includes a second pairadjustable loops. The graft can be passed through the tibial tunnel andtensioned relative to the femoral and tibial tunnels. A fixation membercan be implanted into the tibial tunnel to fix the tensioned graft tothe tibia. A second femoral fixation member can be implanted relative tothe femoral tunnel such that a distal end of the second femoral fixationmember is positioned adjacent the first end of the femoral tunnel to fixthe tensioned graft relative to the first end of the femoral tunnel.

Further areas of applicability will become apparent from the descriptionprovided herein. The description and specific examples in this summaryare intended for purposes of illustration only and are not intended tolimit the scope of the present disclosure.

DRAWINGS

The present teachings will become more fully understood from thedetailed description, the appended claims and the following drawings.The drawings are for illustrative purposes only of selected embodimentsand not all possible limitations, and are not intended to limit thescope of the present disclosure.

FIG. 1 is a perspective view of an exemplary graft strand tensionerhaving arms in a non-deployed position in accordance with the teachingsof the present disclosure;

FIG. 2 is an exploded view of components of the tensioner of FIG. 1 inaccordance with the teachings of the present disclosure;

FIG. 3 is a side view of the tensioner of FIG. 1 in accordance with theteachings of the present disclosure;

FIG. 4 is a sectional view of the tensioner of FIG. 1 in accordance withthe teachings of the present disclosure;

FIG. 5 is a perspective view of an outer handle body of the tensionerhaving a tension release member in accordance with the teachings of thepresent disclosure;

FIG. 6 is a perspective view of an inner handle body of the tensioner inaccordance with the teachings of the present disclosure;

FIG. 7 is a perspective view of an arm support member of the tensionerin accordance with the teachings of the present disclosure;

FIG. 8 is a perspective view of a tensioning arm of the tensioner inaccordance with the teachings of the present disclosure;

FIG. 9 is a perspective view of the tensioner showing the ratchetingmember in an advanced position and the tensioning member and arms inexemplary deployed or use positions in accordance with the teachings ofthe present disclosure;

FIG. 10 is a perspective view of a ratcheting member of the tensioner inaccordance with the teachings of the present disclosure;

FIG. 11 is a side view of a driver shaft of the tensioner in accordancewith the teachings of the present disclosure;

FIG. 12 is a perspective view of an exemplary implant for use with thetensioner in accordance with the teachings of the present disclosure;

FIG. 13 is a side view of the implant of FIG. 12 in accordance with theteachings of the present disclosure;

FIG. 14 is a sectional view of the implant of FIG. 13 in accordance withthe teachings of the present disclosure;

FIGS. 15-17 are perspective views of exemplary alternative implants foruse with the tensioner in accordance with the teachings of the presentdisclosure;

FIGS. 18 and 19 depict exemplary adjustable knotless suture constructsthat can be used in an ACL reconstruction procedure in accordance withthe teachings of the present disclosure;

FIGS. 20-24 depict coupling a graft to a femur and tibia in an exemplaryACL reconstruction procedure in accordance with the teachings of thepresent disclosure;

FIG. 25 depicts a partial section view of an exemplary implant securinggraft strands to the tibia in accordance with the teachings of thepresent disclosure;

FIG. 26 depicts a partial perspective view of an implant coupling fourgrafts strands to the tibia in accordance with the teachings of thepresent disclosure;

FIG. 27 depicts a sectional view of FIG. 26 in accordance with theteachings of the present disclosure;

FIG. 28 is a perspective view illustrating an exemplary placement offour graft strands about the implant with the tibial tunnel removed inaccordance with the teachings of the present disclosure;

FIGS. 29-30 are views depicting another exemplary ACL reconstructionprocedure in accordance with the teachings of the present disclosure;

FIGS. 31A-32 are views depicting another exemplary ACL reconstructionprocedure in accordance with the teachings of the present disclosure;

FIGS. 33A-34 are views depicting an implant for coupling a graft to thetibia and an associated exemplary ACL reconstruction procedure inaccordance with the teachings of the present disclosure;

FIGS. 35A-36 are views depicting an implant for coupling a graft to thetibia and an associated exemplary ACL reconstruction procedure inaccordance with the teachings of the present disclosure;

FIGS. 37A-40 are views depicting exemplary implants for coupling a graftto bone in an ACL reconstruction procedure in accordance with theteachings of the present disclosure; and

FIG. 41 depicts another exemplary ACL reconstruction procedure inaccordance with the teachings of the present disclosure.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is notintended to limit the present disclosure, its application, or uses. Itshould be understood that throughout the drawings, correspondingreference numerals indicate like or corresponding parts and features.Throughout the description, exemplary embodiments are provided so thatthis disclosure will be thorough, and will fully convey the scope tothose who are skilled in the art. Numerous specific details are setforth such as examples of specific components, devices, systems and/ormethods, to provide a thorough understanding of exemplary embodiments ofthe present disclosure. It will be apparent to those skilled in the artthat specific details need not be employed, that exemplary embodimentsmay be embodied in many different forms and that neither should beconstrued to limit the scope of the disclosure. In some exemplaryembodiments, well-known processes, well-known device structures, andwell-known technologies are not described in detail.

Turning now to FIGS. 1-14 of the drawings, an exemplary tensioner 10 andan associated implant 14 are shown in accordance with the teachings ofthe present disclosure. As will be discussed in greater detail below,tensioner 10 and implant 14 can be used in connection with an ACLreconstruction procedure (e.g., FIGS. 20-28) where one or more loopedgraft bundles can be tensioned and coupled relative to a tibial tunnel.As will also be discussed below, in one exemplary configuration, asurgeon can operate tensioner 10 with one hand and tensioner 10 canprovide equal or substantially equal tension to four graft strandsextending from the tibial tunnel.

Tensioner 10 can be wholly disposable or reusable or partiallydisposable or reusable and can include an outer handle body 18, an innerhandle body 22, a tensioning arm assembly 26, a ratcheting bone engagingmember 30 and a driver shaft 34. Outer handle body 18 can include ahollow body 38 having a proximal end 42 and a distal end 46, as shownfor example in FIG. 5. Proximal end 42 can include a flange 50 for usein supporting a surgeon or other user's hand and distal end 46 caninclude a pair of outwardly extending flanges 54 having arm engagingsurfaces 58. Hollow body 38 can include a plurality of ribs or otherprotrusions 62 to aid the surgeon in gripping outer handle body 18. Anaperture 66 can be formed in body 38 for receiving a tension releasemember 70, which will be discussed below in greater detail.

Inner handle body 22 can be received in outer handle body 18 and caninclude a proximal end 78 and a distal end 82, as shown for example inFIG. 6. Proximal end 78 can include a first portion 86 having a flange90 formed on a distal end thereof and a second portion 94 having aC-shaped configuration 98 in cross section extending from flange 90 todistal end 82. As will be discussed in greater detail below, theC-shaped configuration 98 of second portion 94 can axially receivedriver shaft 34 therein, as shown for example in FIG. 4. Outer handlebody 18 can include an internal flange 102 having an aperture 106 sizedand shaped to receive and support the inner handle body 22 andratcheting member 30, as also shown in FIG. 4.

Tensioning arm assembly 26 can include an arm support member 110 and apair of tensioning arms 114, as shown for example in FIGS. 7 and 8 withreference to FIG. 2. Arm support member 110 can include a body 118having a passage 122 therethrough and a pair of centrally positionedrecesses 124 configured to receive a corresponding pair of projections130 (FIG. 6) extending from distal end 82 of inner handle body 22. Eachrecess 124 can include an open end 126 and an arcuate shaped closed end128. As will be discussed in greater detail below, arm support member110 can rotate or pivot about an axis 132 perpendicular to alongitudinal axis 134 (FIG. 2) of tensioner 10 to cooperate withtensioning arms 114 to provide equal or substantially equal tension tograft strands that are coupled to tensioning arms 114. In the exemplaryconfiguration illustrated, body 118 can have a rectangular shape witharm attachment members 138 extending from opposite lateral ends 142thereof. Each arm attachment member 138 can include a flange or otherretaining member 146 extending therefrom to retain the respectivetensioning arm 114 thereon.

Each tensioning arm 114 can include a body portion 154 having a centralaperture 158 configured to receive attachment member 138 for removablycoupling tensioning arm 114 to arm support member 110. Each tensioningarm 114 can be rotatably coupled to a respective attachment member 138,where rotation of tensioning arms 114 about axis 160 aids in providingthe equal or substantially equal tension to grafts strands coupledthereto. In other words, having arm support member 110 rotate aboutfirst axis 132 and tensioning arms 114 each rotate about second axis 160allows each strand 470 (FIGS. 21 and 22) of the graft bundle to beseparately tensioned and balanced. In the exemplary configurationillustrated, aperture 158 can include a recess 162 sized and shaped toreceive retaining member 146 therethrough. Body portion 154 can includeflexible member or suture attachment arrangements 166 at opposedlongitudinal ends thereof to facilitate coupling the flexible member orsuture 170 (e.g., FIG. 22) extending from a respective graft strandthereto, as will be discussed in greater detail below.

Briefly, however, each attachment arrangement 166 can include first andsecond attachment areas 174, 178 for use in securing the suture thereto.In one exemplary configuration, first attachment area 174 can be used toinitially receive the suture 170, such as by wrapping the suture aroundthe attachment area 174. The second attachment area 178 can include aslot 186 between adjacent flanges 190 sized and shaped to provide aninterference fit to a suture received therein. In this regard, secondattachment area 178 can be used to secure an end of suture 170 therein,as shown for example in FIG. 23. It should be appreciated however, thatfirst and second attachment areas 174, 178 can be used individually orin combination to removably couple a respective suture 170 thereto. Inanother exemplary configuration, each arm 14 can include a thirdattachment arrangement 166 centrally positioned between the longitudinalends, as shown for example in FIGS. 8 and 9. The third attachmentarrangement 166 could be used, for example, with a graft bundle havingan additional two ends.

The tensioning arms 114 can also include first and second engagementsurfaces 202, 206 configured to engage respective surfaces 58 of flanges54 in the non-deployed and deployed positions of tensioning arms 114, asshown in FIG. 8 with reference to FIGS. 1 and 22. For example, one ofsecond engagement surfaces 206 can engage respective surfaces 58 offlanges 54 when tensioning arms 114 are in the pre-use or non-deployedposition, such as a shipping or storage position, as shown for examplein FIG. 1. The tensioning arms 114 can be rotated to the initial use ordeployed position where first engagement surfaces 202 of tensioning arms114 engage respective surfaces 58 of flanges 54, as shown for example inFIG. 22.

The ratcheting member 30 can include a first portion 214 defining adistal end 218 and a second portion 222 extending therefrom and defininga proximal end 224, as shown for example in FIG. 10. First portion 214can include a bone engaging member or foot 228 at the distal end 218thereof and can include an aperture 232 for receiving a bone spike orother bone engaging or fixation member 236 (FIG. 2). Bone spike 236 caninclude a longitudinal length so as to extend beyond an outer surface240 of distal end 218, as shown for example in FIG. 3. First portion 214can also include a longitudinal aperture or throughbore 244 sized andshaped to receive driver shaft 34 therethrough, as will be discussed ingreater detail below. In the exemplary configuration illustrated, boneengaging foot 228 can include a substantially U-shaped configuration 252configured to align with a tibial tunnel and receive implant 14 and aportion of driver shaft 34 therethrough, as will also be discussed belowin greater detail.

The second portion 222 can extend from the first portion 214 and caninclude ratchet teeth 258 along a longitudinal length of a first side262 thereof. Ratchet teeth 258 can be configured to engage ratchetingpawl 266 (FIG. 5) formed in hollow body 38 of outer handle body 18.Ratcheting pawl 266 can be biased into engagement with ratchet teeth 258when ratcheting member 30 is positioned in an assembled configurationwithin outer handle body 18, as will be discussed in greater detailbelow. The tension release member 70 can be in selective engagement withratcheting pawl 266. In this regard, movement of tension release member70 relative to aperture 66 and ratcheting pawl 266 can selectivelydisengage ratcheting pawl 266 from ratchet teeth 258 to release anytension imparted on associated graft strands coupled to tensioning arms114, as will also be discussed in greater detail below.

The second portion 222 can include a second side 274 opposite first side262, as shown for example in FIG. 10. Second side 274 can be configuredto mate with an open end or side 278 of the C-shaped second portion 94of inner handle body 22, as shown for example in FIG. 9 with referenceto FIG. 6. Second side 274 can also include a longitudinally extendingrib or protrusion configured to be received in the open end of theC-shaped second portion 222 to guide the ratcheting member 30 relativeto inner handle body 22. In one exemplary configuration, thelongitudinally extending protrusion can include an arcuate outer surfacein cross-section configured to slidably engage an outer surface 286(FIG. 11) of driver shaft 34 when the driver shaft 34 is received ininner handle body 22 in an assembled configuration of tensioner 10.

Driver shaft 34 can include a shaft body 294 extending from a proximalend 298 to a distal end 302, as shown for example in FIG. 11. In theexemplary configuration illustrated, proximal end 298 can include animpact or driver receiving member 300 secured thereto or integrallyformed thereon. Distal end 302 can be configured to receive implant 14thereon, as will be discussed below in greater detail. Briefly, however,distal end 302 can include an implant receiving portion 306 configuredto be received in a bore 310 (FIG. 13) of implant 14. An open end ofbore 310 can include a shoulder 314 configured to engage a correspondingshoulder 318 at a proximal end 322 of implant receiving portion 306. Aswill be discussed in greater detail below, driver shaft 34 can beimpacted at proximal end 298 to drive implant 14 into a tibial tunnel,during which an impact force is transmitted from driver shaft 34 toimplant 14 via engagement of corresponding shoulders 314, 318.

Implant 14 can include body 326 having an open proximal end 330, aclosed or substantially closed distal end 334, and the closed orsubstantially closed end bore 310 extending from proximal end 330 towarddistal end 334, as shown for example in FIGS. 12-14. Body 326 caninclude an outer surface 338 having a plurality of annular portions orsegments 340 of increasing outer diameter in a direction from the distalend 334 toward the proximal end 330. In the exemplary configurationillustrated, implant 14 can include four segmented sections 340A-340D,each having an increasing diameter as shown in FIG. 13. The distal end334 can include a pair of opposed flattened sections 348 configured toaid in orientating the graft strands about implant 14, as will bediscussed in greater detail below. In this regard, body 326 can alsoinclude four longitudinally and radially outwardly extending ribs 352extending between the proximal and distal ends 330, 334 about outersurface 338. In the exemplary configuration illustrated, ribs 352 can becircumferentially spaced 90 degrees apart to divide outer surface 338into four equally spaced quadrants 356A-356D configured to receive, inone exemplary configuration, four respective graft strands, as shown forexample in FIG. 28.

Proximal end 330 of implant 14 can include a 45 degree angle relative toa longitudinal axis of the implant so as to mate in a substantiallyflush or otherwise substantially parallel manner with an outer surfaceof a tibia when implanted into a tibial tunnel formed at an approximate45 degree angle to a longitudinal axis of the tibia. A protrusion 364can extend from the proximal end 330 and can be configured to engage theouter surface of the tibia 454 to provide a tactile feel to the surgeonindicative of the implant 14 being driven an appropriate distance intothe tibia and to prevent implant 14 from being driven too deeply intothe tunnel, as shown for example in FIG. 26 with reference to FIG. 12.Bore 310 of implant 14 can include a reduced diameter portion 372 at aclosed or substantially closed end 376 thereof that is sized and shapedto provide an interference fit with an end of the implant receivingportion 306 of driver shaft 34. The interference fit can aid inretaining implant 14 in a desired orientation relative to driver shaft34 and the tibial tunnel during an ACL reconstruction procedure, as willbe discussed below in greater detail.

In one exemplary configuration, driver shaft 34 can include athroughbore or cannulation 380 and implant 14 can include a throughbore384 at a distal end thereof such that the bores 380, 384 are inalignment when implant 14 is received on driver shaft 34, as shown forexample in FIGS. 4, 11 and 14. As will be discussed in greater detailbelow, the throughbores 380, 384 can receive a guidewire 388 (FIG. 25)for assisting in guiding implant 14 relative to the tibial tunnel 450.

With particular reference to FIGS. 1-4, an assembly configuration oftensioner 10 will now be discussed in greater detail. A spring 400 canbe received over the second portion 94 of inner handle body 22 such thata proximal end 404 of spring 400 abuts flange 90. Inner handle body 22can then be inserted into outer handle body 18 such that the distal end82 of inner handle body 22 extends beyond the distal end 46 of outerhandle body 18. Tension arm assembly 26 can be rotatably coupled to thedistal end 46 of inner handle body 22 such that the recesses 124 of armsupport member 110 engage the corresponding projections 130 of innerhandle body 22. The second portion 94 of inner handle body 22 caninclude a length that cooperates with spring 400 such that a distal end408 of spring 400 engages internal flange 102 of outer handle body 18when tension arm assembly 26 is coupled to inner handle body 22, asdiscussed above. In this regard, spring 400 can exert a slight biasforce against inner handle body 22, thereby urging inner handle body 22proximally relative to outer handle body 18 until tension arm assembly26 engages the distal end 46 of outer handle body 18.

In the exemplary configuration illustrated, one of the engagementsurfaces 202, 206 of tensioning arms 114 can contact respective flanges54 of outer handle body 18 under the bias force of spring 400 when thetensioner 10 is otherwise not in use. For example, when tensioning arms114 are in the non-deployed or first position, as shown in FIG. 1,engagement surface 206 of tensioning arm 114 can engage flanges 54 andthe bias force of spring 400 in cooperation with the mating engagementof surfaces 202 and flanges 54 can maintain the arms in the non-deployedposition. Similarly, tensioning arms 114 can be rotated to the deployedor second position, as shown for example in FIG. 22, and can bemaintained in this position by the bias force of spring 400 incooperation with the mating engagement of surfaces 202 and flanges 54.For example, surface 202 can be orthogonal to surface 206, as shown inFIG. 7, such that when one or both tensioning arms 114 are rotatedninety degrees from the first position to the second position, the biasforce of spring 400 in cooperation with the mating engagement of surface202 and flanges 54 can maintain the tensioning arms 114 in the deployedor second position.

Ratcheting member 30 can be received through tension arm assembly 26 andinto outer handle body 18 about the open end of C-shaped second portion94 of inner handle body 22, as briefly discussed above. Drive shaft 34can be received through proximal end 78 of inner handle body 22 suchthat it extends into and through C-shaped second portion 94 andthroughbore 244 of ratcheting member 30, as shown for example in FIGS.1, 2 and 4. Implant 14 can be coupled to implant receiving portion 306of driver shaft 34. It should be appreciated that the order or sequenceof assembled components of tensioner 10 discussed above is merelyexemplary and other assembly sequences are possible and contemplatedherein.

With additional reference to FIGS. 18-28, operation of tensioner 10 willnow be discussed in greater detail in connection with an exemplary ACLreconstruction procedure. The exemplary ACL reconstruction procedurewill make reference to a first or tibial tunnel 450 formed or drilledinto a tibia 454 and a second or femoral tunnel 458 formed or drilledinto a femur 462, as shown for example in FIG. 20. The tibial tunnel 450can include a first end or entrance 452 and a second end or exit 456opposite of a joint space 460 between the femoral and tibial tunnels.Similarly, femoral tunnel 458 can include a first end or entrance 466adjacent joint space 460 and can include a second end or exit 474, orcan be formed as a blind tunnel. In one exemplary configuration, thetibial tunnel 450 can be formed at about a 45 degree angle to alongitudinal axis of the tibia, as is also known in the art. The tunnels450, 458 can be formed in any appropriate manner, such as thosegenerally known in the art, and will not be described in further detailherein.

Once the tunnels 450, 458 are formed, a natural or artificial graft loopor bundle 464 can be passed through the tibial tunnel 450 and into thefemoral tunnel 458 as shown for example in FIGS. 20 and 21. In theexemplary configuration, the graft bundle 464 can include two graftloops 468 looped around an adjustable self-locking flexible member orsuture construct 472 (FIGS. 18 and 19). The two graft loops 468 can thusinclude four graft strands 470 extending from an exemplary flexiblemember construct 472, as shown for example in FIG. 20. It should beappreciated that while the discussion continues with reference to twograft loops and four graft strands, various other graft configurationscan be used, including more or less graft loops and/or individual graftstrands secured together at one end. In one exemplary aspect, graft 464can include a synthetic or natural graft, such as an autograft or anallograft.

Adjustable self-locking flexible member construct 472 can include adouble loop configuration 472A shown in FIG. 19 or a bowtie loopconfiguration 472B shown in FIG. 18. With particular reference to FIG.18, adjustable flexible member construct 472B can include a hollowflexible member or suture 478 having a first end 482 and a second end486, and can include a body 490 that defines a longitudinal passageportion 494 therein between first and second ends 482, 486. The passageportion 494 can define a pair of apertures 498, 502 at opposed endsthereof. To form construct 472B, the first end 482 can be passed throughaperture 498 and passage portion 494 and out aperture 502 such that aportion 506 of flexible member 478 following first end 482 extendsthrough passage portion 494. In a similar manner, second end 486 can bepassed through aperture 502 and passage portion 494 and out aperture 498such that a portion 510 of flexible member 478 following second end 486also extends through passage portion 494. This configuration forms twoloops 514 and 514′, as shown in FIG. 18. It should be appreciated thateach of the first and second ends 482, 486 can alternatively be pushedthrough a respective space defined between adjacent individual fibers ofthe braided flexible member 478 such that the respective spaces definedbetween fibers comprise apertures 498, 502 in communication with aninterior longitudinal passage.

The pulling or tensioning of ends 482, 486 can cause movement ofportions 506, 510 relative to passage portion 494, and the loops 514,514′ can be reduced to a desired size or placed in a desired tension.Tension in loops 514, 514′ can cause the body 490 defining the passageportion 494 to be placed in tension and therefore cause passage portion494 to constrict about portions 506, 510 passed therethrough. Thisconstriction reduces the diameter of passage portion 494, thus forming amechanical interface between the exterior surfaces of portions 506, 510and an interior surface of passage portion 494. This constrictionresults in static friction between the interior and exterior surfaces atthe mechanical interface, causing the adjustable flexible member 478 to“automatically” lock in a reduced size or diameter configuration inwhich tension is maintained. Flexible member construct 472B withadjustable loops 514, 514′ can be used to position and tension areplacement graft, such as in an ACL reconstruction procedure, as willbe discussed herein.

With reference to FIG. 19 and continuing reference to FIG. 18,adjustable flexible member construct 472A can be formed to include adouble loop configuration having two loops 514, 514′ that each traversea path from one end of passage portion 494 to the other end thereof,instead of each loop being disposed at respective opposite ends ofpassage portion 494 as in construct 472B. Flexible member construct 472Acan be formed by passing the first end 482 of the flexible memberthrough aperture 502, through passage portion 494 and out aperture 498.The second end 486 can be passed through aperture 498, through thepassage portion 494 and out the aperture 502. In various aspects, thefirst and second apertures 498, 502 can be formed during the braidingprocess as loose portions between pairs of fibers defining the flexiblemember 478, as discussed above. Passing ends 482, 486 through theapertures 498, 502 can form the loops 514, 514′. The loops 514, 514′ candefine mount or summit portions 528, 528′ of the adjustable flexiblemember construct 472A and can be disposed generally opposite from thepassage portion 494. Flexible member construct 472A with adjustableloops 514, 514′ can be similarly used to position and tension areplacement graft, such as in the ACL reconstruction procedure.

The longitudinal and parallel placement of the first and second ends482, 486 of the flexible member 478 within the passage portion 494resists the reverse relative movement of the first and second portions506, 510 of the flexible member construct 472 once it is tightened. Thetensioning of the ends 482, 486 can cause relative translation of theportions 506, 510 relative to passage portion 494. Upon applying tensionto the first and second ends 482, 486, the loops 514, 514′ can bereduced to a desired size or placed in a desired tension. Tension in theloops 514, 514′ can cause the body of the flexible member 478 definingthe passage portion 494 to be placed in tension and therefore causepassage portion 494 to constrict about the portions 506, 510 similarlyto the constriction discussed above with respect to construct 472B. Thisconstriction can cause the adjustable flexible member construct 472A to“automatically” lock in a reduced size or smaller diameter configurationwithout the use of a knot. A further discussion of the flexible memberconstructs 472 is provided in U.S. patent Ser. No. 11/541,506 filed onSep. 29, 2006 entitled “Method and Apparatus for Forming a Self-LockingAdjustable Suture Loop” assigned to Biomet Sports Medicine, LLC, nowU.S. Pat. No. 7,601,165, and the disclosure of which is incorporated byreference herein.

With reference to FIG. 20, passage portion 494 of flexible memberconstruct 472 can be coupled to a femoral fixation member, such as afixation member 550, to facilitate femoral fixation or retention ofgraft 464 relative to femoral tunnel 458. The fixation member 550 canbe, for example, a product sold by Biomet Sports Medicine, LLC under thename ToggleLoc™. A further discussion of the fixation member 550 can befound in U.S. Pat. No. 7,601,165. Fixation member 550 with construct 472coupled thereto can be passed through the tibial and femoral tunnels450, 458 and coupled to an outer surface 554 of femur 462, as shown inFIG. 20. Fixation member 550 can be sized and shaped to include a firstprofile that allows insertion through the tibial and femoral tunnels450, 458, and a second profile that allows engagement with a positivelocking surface upon rotation outside of the femoral tunnel 458. Itshould be appreciated that other apparatus and associated techniques canbe used for femoral fixation in connection with an ACL reconstructionprocedure, such as for example a femoral cross pin with the blindfemoral tunnel and/or those discussed below in connection with one ormore of FIGS. 29-40.

At this point, graft 464 can be passed through the loops of construct472 extending from tibial tunnel 450. Tensioning of the first and secondends 482, 486 applies tension to the loops, thus pulling the graft 464into the tibial and femoral tunnels 450, 458, as shown in FIG. 21. Inthis regard, the first and second ends 482, 486 can extend through thetibial and femoral tunnels 450, 458 and then be tensioned. In thisconfiguration, the ends 482, 486 can then be removed from the tibialtunnel 450 such that they exit through the joint space 460, as shown inFIG. 21. Alternatively, the ends 482, 486 can extend only through thefemoral tunnel 458 and then through the joint space 460 before they aresubsequently tensioned. In the exemplary configuration shown in FIG. 21,the loops of construct 472 can be fully tensioned to draw graft 464 upto passage portion 494. In an alternative exemplary configuration, theloops can be tensioned to draw graft 464 into the femoral tunnel andproximate passage portion 494, while stopping short of fully tensioningthe loops to thereby provide for further tensioning of the loops aftertibial fixation of the graft has occurred, as will be discussed below ingreater detail.

With particular reference to FIGS. 22-27, tensioning and tibial fixationof graft 464 with tensioner 10 will now be discussed in greater detail.After coupling graft 464 to femur 462 with member 550, the four strands470 can extend through and exit the tibial tunnel 450, as shown in FIG.22. At this point, tensioner 10 can be positioned or aligned with thetibial tunnel 450 such that the foot 228 of ratcheting member 30 isapproximately parallel to an adjacent surface of the tibia, as alsoshown in FIG. 22. As discussed above, the foot 228 can include aforty-five degree angle relative to the longitudinal axis 134 oftensioner 10 so as to align the tensioner longitudinal axis 134 with anaxis of the tibial tunnel 450, which can also be formed at a forty-fivedegree angle relative to a longitudinal axis of the tibia 454. It shouldbe appreciated that other angles can be used for the foot 28 and tunnel450. In one exemplary configuration, the guidewire 388 can be insertedinto the tibial tunnel such that one end extends into the joint space460 and the other end extends from an opposite end 456 of the tibialtunnel 450. In this configuration, the tensioner 10 can be aligned withthe tibia 454 such that the guidewire 388 is received into throughbore380 of driver shaft 34. The guidewire 388 can include a predeterminedlength so as to not extend to the proximal end 298 of driver shaft 34.

The tensioning arms 114 can be rotated from the first non-deployedposition shown in FIG. 1 to the second deployed position shown in FIG.22 in anticipation of coupling the graft strands 470 thereto. It shouldbe appreciated that tensioning arms 114 can be placed in the deployedposition before or after aligning the tensioner 10 with the tibialtunnel 450. Similarly, the graft strands 470 can be coupled to thetensioning arms 114 before or after aligning tensioner 10 relative totibial tunnel 450. Each graft strand 470 can be coupled to a respectiveattachment arrangement 166 at the longitudinal ends of each tensioningarm 114. In this regard, each arm can be coupled to two graft strands470 via suture or flexible member 170 coupled to the respective graftstrands, as shown in FIG. 22. At this point, the tensioning arms 114 canbe engaged with outer body flanges 54, as also shown in FIG. 22.

To tension graft strands 470 a first time, the surgeon can apply a forceto the outer handle body 18, such as by pulling with one hand againstflange 50, to compress spring 400 between flanges 102 and 90 and movethe outer handle body 18 relative to the inner handle body 22 andratcheting member 30, as shown for example in FIG. 23. As the tensionarm assembly 26 is coupled to the inner handle body 22 and the graftstrands 470, compressing spring 400 by moving outer handle body awayfrom the tibia exerts a force on the inner handle body 22 toward thetibia thereby pushing the ratcheting member 30 incrementally toward thetibia 454. This action increases a longitudinal length of the overalltensioner 10 and thus applies an increasing amount of tension to graftstrands 470 by moving tensioning arms 114 farther away from tibialtunnel 450. As outer handle body 18 is moved to apply tension to strands470, ratchet pawl 266 engages the ratchet teeth 258 to maintain adesired position of outer handle body 18 relative to the ratchetingmember 30 and thus maintain the desired tension. In addition, as tensionis applied to the graft strands 470 with tensioner 10, bone spike 236can engage the tibia 454 to aid in maintaining the position of tensioner10 with tibial tunnel 450 during the ACL reconstruction procedure. Inthis regard, the tensioner 10 can stay in place relative to the tibialtunnel and tibia when under tension and thus does not require a user tohold or otherwise support tensioner 10 to maintain its position relativeto the tibia when under tension.

The first portion 86 of inner handle body 22 can also include a scale570 having indicia 574 indicative of an amount of tension being impartedonto graft strands 470 by operation of tensioner 10 as shown for examplein FIGS. 9, 22 and 23. In this regard, spring 400 can be calibratedrelative to scale indicia 574 such that as outer handle body 18 is movedrelative to inner handle body 22 to tension the graft strands 470, theflange 50 can align with a particular indicia 574 to indicate an amountof tension being placed on graft strands 470.

As tension is applied to graft strands 470 as discussed above, tensionarm assembly 26 moves away from the distal end of outer handle body 18,as shown in FIG. 23. At this point, arm support member 110 can nowrotate about axis 162 relative to inner handle body 22, as also shown inFIG. 23. Allowing arm support member 110 to rotate relative to innerhandle body 22 in cooperation with allowing tensioning arms 114 toindividually rotate about axis 160 relative to arm support member 110provides for being able to apply equal tension to each of graft strands470. In this regard, the rotating capabilities of arm support member 110and arms tensioning 114 can compensate for differences in length ofindividual graft strands 470 and/or the accompanying attachment suturesto balance the tension in each graft strand. With this compensationcapability, the surgeon or clinician does not have to ensure that eachgraft strand 470 and accompanying suture exiting the tibial tunnel 450has the same length from the tunnel 450 to the tensioner 10.

Once tension is applied to the graft strands 470 as discussed above, thetensioner 10 can maintain the tension of strands 470 until released viaactuation of tension release member 70. In this regard, upon tensioninggraft strands 470 with tensioner 10, the tensioner can remain secured tothe tibia 454 and aligned with the tibial tunnel 450 without the aid ofthe surgeon or clinician continuing to hold the tensioner 10. With thiscapability of tensioner 10, the surgeon can, for example, cycle the kneejoint to remove any laxity from the tensioned graft while the tensioneressentially self-maintains its position relative to the tibia 454 andtibial tunnel 450. If such cycling of the joint results in a decrease oftension on the graft strands 470, the surgeon can again pull or moveouter handle body relative to inner handle body to tension the graftstrands 470 a second time to increase the tension on strands 470 to thedesired amount.

With the desired tension being applied to the graft strands by tensioner10 and the knee joint being optionally cycled as discussed above, theimplant 14 can be implanted into the tibial tunnel 450 to secure thetensioned graft strands 470 to the tibia 454, as will be discussed ingreater detail below. It should be appreciated that by securing thegrafts strands 470 about the horizontally and vertically spaced apartfour attachment arrangements 166 of the tension arm assembly 26, thegraft strands 470 are effectively separated into four quadrants at theexit of the tibial tunnel 450 corresponding to the four quadrants356A-356D of implant 14 as shown for example in illustrative FIG. 28.

Implant 14 can then be advanced by translating driver shaft 34 relativeto the inner and outer handle bodies 18, 22 and the ratcheting member 30such that implant 14 is proximate the entrance of tibial tunnel 450. Theopposed flattened sections 348 at the distal end of implant 14 can aidin separating the graft strands 470 upon implantation such that twostrands 470A, 470B are on one side of the implant 14 and the other twostrands 470C and 470D are on the opposite side of the implant 14 asshown for example in illustrative FIG. 28. The longitudinal ribs 352 canaid in further separating the strands 470 upon implantation such thateach strand 470A-470D is positioned in a respective quadrant 356A-356D.It should be appreciated that while strands 470A-470D have beendiscussed above as correlating to quadrants 356A-356D, strands 470A-470Dcan be placed in different quadrants 356A-356D so long as one strand isin each quadrant 356A-356D.

A driving or impacting instrument 580 can be used to impart a drivingforce on the proximal end 298 and translate driver shaft 34 relative tothe outer and inner handle bodies 18, 22 and ratcheting member 30 alongthe axis of the tibial tunnel 450. Such translation of driver shaft 34can drive implant 14 into tibial bone tunnel 450 about graft strands470A-470D to fix graft 464 relative to the tibia 454, as shown in FIG.24 with reference to FIGS. 25-27. Implant 14 can be driven axially intothe tibial tunnel 450 until protrusion 364 extending from the proximalend 330 thereof engages an adjacent outer surface of the tibia 454.Protrusion 364 can serve as a stop and/or provide a tactile feel to thesurgeon that implant 14 has been driven to the desired depth. In anexemplary configuration, driver shaft 34 can also include indicia, suchas an indicator band 588, to provide an additional indication of thedesired drive depth. In this configuration, the indicator band 588 canbe adjacent a proximal end 592 of the throughbore 244, as shown forexample in FIG. 24.

As the implant 14 is driven into the tibial bone tunnel, implant 14 cancompress the graft strands between an outer surface 338 of implant 14and an inner surface or wall 604 of the tibial tunnel 450, as shown forexample in FIGS. 25 and 27. In one exemplary configuration shown in FIG.25, implant 14 can compress each graft strand 470A-470D to substantiallyfill an area between adjacent longitudinal ribs 352 and the innersurface 604 of the tibial tunnel 450 and the outer surface 338 ofimplant 14. In this regard, implant 14 can include an increasing outerdiameter with each segmented section 340A-340D, as discussed above,where the first segment 340A includes an outer diameter less than aninner diameter of wall 604 of tibial bone tunnel 450, and the lastsegmented section 340D can include a diameter greater than the innerdiameter of wall 604.

In one exemplary configuration and with reference back to FIGS. 12 and13, each segment can include an inner diameter increasing byapproximately 0.5 mm. In this regard, the first segment can include anouter diameter 0.5 mm less than the inner diameter of wall 604, and thelast segment has an outer diameter 1.0 mm greater than the innerdiameter of wall 604. This configuration can provide an interference fitwith the cancellous bone of the tibia 454 where the cancellous bone iscompressed outward by the implant 14 to provide tibial fixation of graftstrands 470, as discussed above.

Upon driving implant 14 into tibial tunnel 450 to provide the tibialfixation of graft strands 470, any graft strands extending out from thetibial tunnel 450 and implant 14 can be trimmed and removed. Theoptional guidewire 388, if used, is also removed. Tensioner 10 will thenno longer be coupled to the tibia 454 and can be subsequently removed.In one exemplary configuration, the loops of construct 472 can betensioned to draw graft 464 into the femoral tunnel and proximatepassage portion 494, while stopping short of fully tensioning the loopsto thereby provide for further tensioning of the loops after tibialfixation of the graft has occurred, as discussed above. In thisconfiguration, the graft 464 can be tensioned a third time, if desired,after removal of tensioner 10 by further tensioning the first and secondends 482, 486 extending from the joint space (FIG. 21). Tensioning theends 482, 486 further reduces the size of the loops and thus appliesadditional tension to the graft strands 470 that are now fixed to tibia454 after the first and second tensions. After tensioning is completed,excess ends 482, 486 extending from tibial tunnel 450 can be removed.

Turning now to FIGS. 15-16, alternative implants 620 and 624 will now bediscussed according to various aspects of the present teachings. Withparticular reference to FIG. 15, implant 620 can include an openproximal end 628 and a closed or substantially closed distal end 632similar to implant 14. Implant 620 can also be configured for use withtensioner 10 in a similar manner as implant 14. As can be seen in FIG.15, proximal end 628 can be angled at 45 degrees relative to alongitudinal axis of implant 620 so as to be substantially parallel orparallel to the tibia 454 upon implantation. Implant 620 can includefour longitudinal extending rib configurations 636 to separate an outersurface 640 into four circumferential quadrants, similar to implant 14discussed above. In the exemplary configuration illustrated, each ribconfiguration 636 can include a plurality of segments 636A.

The outer surface 640 between adjacent rib configurations 636 caninclude a concave shape 644 in cross section and can include a pluralityof graft engaging features 648. In the exemplary configurationillustrated, the graft engaging features 648 can include variousdepressions and/or projections configured to engage the graft strands470. Implant 620 can also include an increasing outer diameter ordimension from the distal end 632 toward the proximal end 628. In oneexemplary configuration, the distal end 632 can include an outerdiameter less than the inner diameter of wall 604 of the tibial tunnel450 and the proximal end 628 can include an outer diameter greater thanthe inner diameter of wall 604.

With particular reference to FIG. 16, implant 624 can include a proximalend 654 and a distal end 658, and can also be configured for use withtensioner 10 in a manner similar to implant 14. Implant 624 can includea body 662 extending from the proximal end 654 toward the distal end 658that transitions into four axially extending and circumferentiallyspaced apart leg members 668. Each leg member 668 can include a proximalend 672 having a width greater than a distal end 676, as shown in FIG.16. In the exemplary configuration illustrated, the distal ends 676 ofeach leg member can terminate in a distal tip or point 680. The body 662can include four longitudinally extending protrusions 684 each axiallyaligned with a respective leg member 668, as shown in FIG. 16. In thisregard, each graft strand 470 can be positioned in the space betweeneach leg member 668 and the corresponding recessed area 688 between eachprotrusion 684.

Turning now to FIG. 17, another alternative implant 700 is illustratedfor use in tibial fixation of graft strands 470 in accordance with anaspect of the present teachings. In one exemplary configuration, implant700 can be used in conjunction with tensioner 10, where tensioner 10 isused to tension graft strands 470 in the manner discussed above. Implant700 can be used to compress the graft strands 470 between the implant700 and the inner diameter of wall 604 of tibial tunnel 450. Implant 700can include a proximal end 704 and a distal end 708 terminating in adistal tip 712. Proximal end 704 can include a head member 716configured to receive an impact or driving force to drive implant 700into tibial tunnel 450 about graft strands 470, as shown for example inFIG. 17. A graft engaging member 720 can be positioned adjacent headmember 716 about a body 724 of implant 700 and can include a graftengaging surface 728. Graft engaging surface 728 can include a pluralityof teeth or projections 732 configured to engage graft strands 470 andaid in fixing strands 470 to tibia 454.

Implant 700 can also include an aperture 736 extending through theimplant proximate the head member 716 and transverse to a longitudinalaxis of implant 700. In the exemplary configuration illustrated in FIG.17, aperture 736 can be positioned between or substantially between headmember 716 and graft engaging member 720, and can receive a fastener 740in securing implant 700 to the tibia 454. A counterbore or countersink744 can be formed in the tibia 454 at the entrance of tibial tunnel 450to receive the graft engaging member 720, as also shown in FIG. 17. Inone exemplary configuration, the body 724 of implant 700 can include adiameter or width that forms an interference fit relative to the innerwall of the tibial tunnel 450.

Turning now to FIGS. 29-30, a femoral fixation arrangement andassociated technique will now be described in accordance with an aspectof the present teachings. With particular reference to FIG. 29, aflexible member construct assembly 750 is shown and can include a firstflexible member construct 472 coupled to fixation member 550 in themanner discussed above. A pair of graft bundles 468 can also be loopedover construct 472 in the manner discussed above. In addition, a secondflexible member construct 472 can be coupled to the loops 514, 514′ andto a graft fixation member 754, as shown in FIG. 29.

Graft fixation member 754 can include a body 758 having a first portion762 defining an aperture 766 adjacent a proximal end 770 thereof, and asecond portion 774 having a plurality of leg members, such as four legmembers 778, extending to and defining a distal end 784 of fixationmember 754. Aperture 766 can receive a portion of the second flexiblemember construct 472 to couple fixation member 754 to the first flexiblemember construct 472, as discussed above and shown in FIG. 29. The firstportion 762 of body 758 can include a diameter or width substantiallyequal to or greater than an inner wall 788 of femoral tunnel 458 so asto be received in femoral tunnel 458 about graft strands 470 in aninterference fit relationship. Alternatively, first portion 762 caninclude a diameter less than inner wall 788 so as to be received aboutgraft strands 470 in a non-interference fit manner relying on legmembers 778 for the femoral fixation, as will be discussed below. Theleg members 778 can be biased radially outward from first portion 762 soas to have an increasing diameter or width in a direction toward distalend 784, as shown in FIG. 29. Graft fixation member 754 can include anynumber of legs 778, such as three or four legs to secure and separatethe four grafts strands 470.

In use, and with reference to FIG. 30, the fixation member 550 can bedrawn through the joint space 460 and up through the femoral tunnel 458such that the fixation member 550 engages the outer surface 554 of thefemur 462 at exit 474 in the manner discussed above. The free ends ofthe first flexible construct 472 can be tensioned to draw the graft intothe femoral tunnel 458 relative to fixation member 550, as shown in FIG.30 and discussed above with reference to FIG. 21. At this point, thegraft fixation member 754 can remain outside of the femoral tunneladjacent the joint space 460 and near the opening 466. The free ends482, 486 of the first and second flexible member constructs 472 canextend from the femoral tunnel out through the joint space 460 and/orcan extend through the femoral and tibial tunnels 458, 450. In oneexemplary configuration, the free ends of the first and second flexiblemember constructs can both extend out of the joint space 460 to providefor tensioning/drawing the graft strands 470 and/or the graft fixationmember 754 after implant 14 or another tibial fixation member isimplanted into tibial tunnel 450. The graft strands 470 can then be fedinto and through the tibial tunnel 450 starting from the joint spaceside. Once the graft strands 470 are fed though the tibial tunnel 450,the grafts strands 470 can be tensioned using tensioner 10 in the mannerdiscussed above or another appropriate tensioning arrangement.

Having tensioned graft strands 470, the free ends of the second flexibleconstruct 472 can be tensioned to draw the graft fixation member 754into the femoral tunnel 458 via the joint space 460. As the graftfixation member 754 is drawn into the femoral tunnel 458, the legmembers 778 can be compressed against their biased outward positionthereby exerting a force on the inner wall 788 of femoral tunnel 458 toprovide femoral fixation and separation of the graft strands 470. In oneexemplary configuration, the graft fixation member 754 can be drawn intothe femoral tunnel 458 such that the distal end 784 of the graftfixation member 754 is positioned at the entrance 466 of the femoraltunnel 458 to provide the femoral fixation of graft strands 470 at thelocation where the graft extends from the femoral tunnel 458 into thejoint space 460. This configuration can prevent movement of the graftstrands 470 at the entrance 466 between flexion and extension andthereby increase wear resistance and stability of the graft 464.

The graft strands 470 can then be fixed to the tibia 454 using theaperture fixation technique discussed above in connection with tensioner10 or another tibial tensioning and fixation technique. Once the graftstrands 470 are fixed to the tibia 454, the free ends of the firstflexible member construct 472 can optionally be tensioned to reduce thesize of loops 514, 514′ and thereby add additional tension to the graftstrands 470 after tibial fixation. By having the free ends 482, 486 ofthe first and second flexible member constructs 472 extend from thefemoral tunnel 458 out through the joint space 460, tensioning of thefirst and/or second flexible member constructs 472 can be accomplishedafter tibial fixation of the graft strands 470, which can obstruct thetibial tunnel 450.

With additional reference to FIGS. 31A-32, another femoral fixationmember and associated technique will now be discussed in accordance withan aspect of the present teachings. A flexible member construct assembly800 is shown and can include a first flexible member construct 472,fixation member 550, and a fixation member 802. Fixation member 802 caninclude a body 804 having a first portion 808 defining a proximal end812 and a second portion 814 extending therefrom and defining a distalend 816. The first portion 808 can include annular ribs or barbs 820sized and shaped to provide for movement in one axial direction, such asinto the femoral tunnel 458, and to resist movement in an oppositedirection as shown in FIG. 31A. The first portion 808 can include atransverse aperture 824 adjacent the proximal end 812 that is configuredto receive the loops 514, 514′ of flexible member construct 472 tocouple fixation member 802 thereto. A pair of notches 828 can beprovided on opposite lateral sides of the first portion 808 in alignmentwith the aperture 824 for receiving a portion of the flexible memberconstruct 472 therein.

The second portion 814 can define an opening 832 configured to receivegraft bundles 468, as shown in FIG. 32. Fixation member 550 of flexiblemember construct assembly 800 can be drawn into the femoral tunnel 458from the joint space 460 or up through the tibial tunnel 450 and can befixed to the outer surface 554 of the femur 462 in the manner discussedabove. The free ends 482, 486 of the flexible member construct 472 canthen be tensioned to draw the fixation member 802 into the femoraltunnel 458 such that the distal end 816 of fixation member 802 is at theentrance 466 adjacent the joint space 460. This configuration can thusalso provide femoral fixation of the graft strands 470 at the entrance466 and exit 474 of the femoral tunnel 458. The graft strands 470 can betensioned using tensioner 10 or another suitable tensioning techniqueand can be fixed to the tibia using implant 14 or another suitableimplant, such as those discussed herein.

With additional reference to FIGS. 33A-34, another flexible memberconstruct assembly 850 is shown in accordance with an aspect of thepresent teachings. Flexible member construct assembly 850 can alsoinclude the first flexible member construct 472, fixation member 550 andfixation member 802 of assembly 800 discussed above. A second flexiblemember construct 472 can be coupled to opening 832 along with graftbundles 468, as shown for example in FIG. 34. A tibial fixation member854 can be used with assembly 850 in place of implant 14. As will bediscussed below, fixation member 854 can be separate from flexibleconstruct 472 such that it can be placed inside loops 514, 514′ at anappropriate time during the procedure.

Fixation member 854 can include a body 858 having a first portion 862defining a proximal end 866 and a second portion 870 extending therefromand defining a distal end 874. First portion 862 can include an outerdiameter or width sized to provide an interference fit with tibialtunnel 450 so as to provide aperture fixation of graft strands 470 whenimplanted in tibial tunnel 450 about graft strands 470. First portion862 can include four axially extending concave portions 878 to receivegraft strands 470 similar to the quadrants 356. The second portion 870can include a plurality of radially outwardly extending tabs orprojections 882 at the distal end 874 to provide a positive stop forfixation member 854 relative to tibial tunnel 450. In this regard,projections 882 can include an outer diameter or dimension greater thanthe inner diameter of tibial tunnel 450.

In use, fixation member 854 of assembly 850 can be drawn into thefemoral tunnel 458 and positioned on the outer surface of the femur 462in a manner similar to that discussed above in connection with assembly800. If fixation member 802 is fed though joint space 460, then graftstrands 470 and the loops and free ends of the second flexible construct472 can be fed into and through the tibial tunnel 450. The free ends ofthe first flexible construct 472 can be tensioned to draw the fixationmember 802 and graft strands 470 into the femoral tunnel 458. Asdiscussed above, the free ends can be tensioned so as to position thedistal end of fixation member 802 adjacent the exit 466 of femoraltunnel 458, as shown in FIG. 34. The grafts strands 470 extendingthrough the tibial tunnel can then be tensioned using tensioner 10 orwith another technique, and the fixation member 854 can then beimplanted into tibial tunnel 450 about graft strands 470 to providetibial fixation of strands 470. To implant fixation member 854 intotibial tunnel 450, the loops 514, 514′ extending from tibial tunnel 450can be looped around fixation member 854 and then tensioned to drawfixation member into tibial tunnel 450 about graft strands 470 to fixstrands 470 to the tibia 454. Fixation member 854 can be drawn intotibial tunnel 450 until projections 882 engage an outer surface of thetibia adjacent tunnel 450, as shown in FIG. 34.

In an exemplary alternative configuration, the first flexible construct472 can be tensioned to draw fixation member 802 partially into thefemoral tunnel 458, but short of the desired position so as to providean ability to further draw fixation member into the femoral tunnel 458after tibial fixation of strands 470, as will be discussed below. Thefixation member 854 can then be positioned in loops 514, 514′ and pulledinto the tibial tunnel to fix graft strands 470 to the tibia in themanner discussed immediately above. After tibial fixation of strands470, the first flexible construct 472 can be further tensioned tofurther draw fixation member 802 into the desired position in thefemoral tunnel 458 and at the same time tension graft strands 470 to thedesired tension.

Turning now to FIGS. 35A-36, another tibial fixation member 900 is shownin accordance with an aspect of the present teachings. Tibial fixationmember 900 can include a proximal end 904, a distal end 908 and a body912 extending therebetween. Body 912 can include a stepped configuration916 having four radially outward extending members 920 forming fourquadrants for graft strands 470. A notch 924 can extend along oppositelateral side of the fixation member 900 for receipt of a portion offlexible member construct 472, as will be discussed below in greaterdetail. Distal end 908 can include a projection 928 having a notch 932formed therein and configured to receive suture loops 514, 514′.

In use, fixation member 900 can be placed in loops 514, 514′ extendingfrom tibial tunnel 450 and drawn into a counterbore 936 formed in thetibia 454 to fix graft strands 470 to tibia 454, as shown for example inFIG. 34. In this regard, fixation member 900 can be used as analternative to fixation member 802 with assembly 800 to effect tibialfixation of graft strands 470. Fixation member 900 can also be used asan alternative to fixation member 700 discussed above in connection withFIG. 17. It should be appreciated that fixation members 854 and 900 canalso be used as an alternative to fixation member 754 discussed above inconnection with FIGS. 29 and 30. In this regard, second flexible memberconstruct 472 of construct assembly 750 can be looped over one offixation members 854 or 900 in place of being coupled to fixation member754.

Turning now to FIGS. 37A-40, a pair of alternative graft fixationmembers will now be discussed in accordance with various aspects of thepresent teachings. With particular reference to FIGS. 37A-38, a graftfixation assembly 950 is shown and can include an outer sheath member954 and an inner or plug member 958. Fixation assembly 950 can be usedfor either femoral or tibial fixation of graft strands 470, as will bediscussed below. Sheath member 954 can include four legs 962 extendingfrom a common tip 966. Each leg member can increasingly extend radiallyoutward from a proximal end 970 to a distal end 974. The legs 962 caninclude an outer diameter or dimension greater than a correspondinginner diameter of the tibial or femoral tunnels. Each leg 962 caninclude a projection 978 extending radially outward therefrom andconfigured to act as a positive stop when the sheath 954 is positionedin the femoral or tibial tunnels.

Plug member 958 can include a body 984 having a proximal end 988 and adistal end 992. Body 984 can include a stepped configuration 996defining a plurality of segments 1002 having an increasing diameter fromthe proximal end 988 to the distal end 992, as shown in FIG. 38. Plugmember 958 can be received in the sheath member 954 inside of legs 962so as to expend legs 962 outward between the four graft strands 470 andagainst a wall of the femoral or tibial tunnels. In this regard, thediameter of the distal end of plug member 958 can be sized to create aninterference fit with the femoral or tibial tunnels when received in thesheath member 954 that is positioned in one of the femoral or tibialtunnels. The proximal end 988 of plug member 958 can include an aperture1006 formed therein and configured to receive loops of flexible memberconstruct 472, as will be discussed below.

In use, the loops of the first or second flexible member construct 472(depending on whether the fixation assembly 950 will be used for femoralor tibial fixation) can be passed through an aperture 982 in the sheathmember 954 and coupled to plug member 958 via aperture 1006. Forexample, and with reference back to FIG. 29, fixation assembly 950 canbe used in place of fixation member 754 where sheath member 954 and plugmember 958 are coupled to the first flexible member construct 472.Alternatively, in another exemplary configuration and with referenceback to FIG. 34, fixation assembly 950 can be used for tibial fixationwhere sheath member 954 and plug member 958 are coupled to the secondflexible member construct 472 of assembly 850 in place of fixationmember 854.

In either femoral or tibial fixation, the sheath member 954 can bepositioned in the respective bone tunnel between graft strands 470 bysliding the sheath member 954 about the loops 514, 514′ until theprojections 978 abut an outer surface of the respective tunnel similarto fixation member 854 shown in FIG. 34. The corresponding flexiblemember construct 472 can then be tensioned to draw plug member 958 intosheath member 954 thereby expanding legs 962 into compressed engagementwith surrounding bone of the bone tunnel to separate and fix graftstrands 470 to the respective femur or tibia.

With additional reference to FIGS. 39A-40, graft fixation assembly 1012will now be discussed. Graft fixation assembly 1012 is similar to graftfixation assembly 950 and can also be used for either femoral or tibialgraft fixation in a similar manner as assembly 950. Graft fixationassembly 1012 can include an outer sheath member 1016 and a plug member1020 configured to be received in the sheath member 1016, as will bediscussed below. Sheath member 1016 can include four leg members 1024extending from an open proximal end 1028 to an open distal end 1032, asshown in FIGS. 39A and 39B. Each leg member 1024 can extend radiallyoutward as it extends from the proximal end 1028 to the distal end 1032such that sheath member 1016 includes an increasing diameter or widthfrom the proximal end 1028 to the distal end 1032, as shown in FIG. 39A.In one exemplary configuration, the diameter at the distal end can belarger than an inner diameter of the femoral or tibial tunnel so as tocreate an interference fit when the sheath member is positioned therein.Each leg member 1024 can include a radially outward projection 1036configured to serve as a positive stop in a similar manner asprojections 978 of fixation assembly 950.

Plug member 1020 can also be similar to plug member 958 and can includea body 1044 having a proximal end 1048 and a distal end 1052. Proximalend 1048 can define an aperture 1056 for receiving flexible memberconstruct 472 and the body can include an increasing diameter from theproximal end 1048 to the distal end 1052. Similar to plug member 958, adiameter of the distal end 1052 of plug member can be greater than adiameter of the proximal end 1028 of legs 1024 so as to expand the legsinto compressive engagement with graft strands 470 and surrounding boneof the femur or tibia. Plug member 1020 can also include notches ordepressions 1058 configured to engage the leg members 1024 and preventrotation of plug member 1020 relative to sheath member 1016.

With additional reference to FIG. 41, another flexible member constructassembly 1070 is shown in accordance with an aspect of the presentteachings. As will be discussed in greater detail below, constructassembly 1070 can be used to provide femoral and tibial fixation at theentrance and exit of the tibial tunnel 450 and the femoral tunnel 458.Construct assembly 1070 can include flexible member construct assembly750 for use in femoral fixation in the manner discussed above and asshown in FIG. 41 with reference to FIGS. 29-30. Alternatively, constructassembly 1070 can use construct assembly 800 in the manner discussedabove for use in femoral fixation at the entrance 466 and exit 474 offemoral tunnel 458, as shown in FIGS. 31A-32.

Construct assembly 1070 can also include a tibial fixation assembly 1074for use in fixing the tensioned graft strands 470 relative to theentrance 452 and exit 456 of tibial tunnel 450, as shown in FIG. 41. Inone exemplary configuration, tibial fixation assembly 1074 can includeimplant 14 having a transverse bore 1078 adjacent the distal end 334with a third flexible member construct 472 coupled thereto. In theexemplary configuration illustrated, fixation member 754 can be coupledto implant 14 via transverse bore 1078 and third flexible memberconstruct 472, as shown in FIG. 41. It should be appreciated that anotch or projection could alternatively be used on implant 14 in placeof bore 1078 to provide for coupling third flexible member construct 472and associated fixation member 754 to implant 14 during the procedure.It should also be appreciated that other tibial fixation membersdiscussed herein can be alternatively used with tibial fixation assembly1074 in place of implant 14.

In operation, construct assembly 1070 can be used to provide femoral andtibial fixation of graft strands 470. In the exemplary configurationillustrated, construct assembly 750 can be used to draw graft strands470 into femoral tunnel 458 and fix graft strands 470 relative to outersurface 554 and entrance 466, as shown in FIG. 41 and discussed above.The tibial fixation assembly 1074 can then be used to provide tibialfixation of the tensioned graft strands 470 relative to the entrance 452and exit 456 of tibial tunnel 450.

In this regard, fixation member 754 can be positioned relative to thejoint space 460 such that third flexible member construct assembly 472extends into joint space 460 and down through tibial tunnel 450 toimplant 14 adjacent exit 456. Once implant 14 is implanted into tibialtunnel 450 to fix the tensioned graft strands 470 relative thereto, freeends 482, 486 of third construct 472 can be tensioned to draw fixationmember 754 into tibial tunnel 450 via joint space 460 and fix thetensioned graft strands 470 relative to entrance 452 of tibial tunnel450. In the exemplary configuration illustrated, fixation member 754 canbe drawn into tibial tunnel 450 such that distal end 784 is adjacententrance 452.

While one or more specific examples have been described and illustrated,it will be understood by those skilled in the art that various changesmay be made and equivalence may be substituted for elements thereofwithout departing from the scope of the present teachings as defined inthe claims. Furthermore, the mixing and matching of features, elementsand/or functions between various examples may be expressly contemplatedherein so that one skilled in the art would appreciate from the presentteachings that features, elements and/or functions of one example may beincorporated into another example as appropriate, unless describedotherwise above. Moreover, many modifications may be made to adapt aparticular situation or material to the present teachings withoutdeparting from the essential scope thereof.

What is claimed is:
 1. A method of placing an ACL grail in a patient,comprising: anchoring an ACL graft to a femur of a patient with a firstgraft strand; a second graft strand, a third grail strand, and a fourthgraft strand of the ACL graft extending out of the femur and through anadjacent tibial tunnel in a tibia of the patient so that the first graftstrand, the second graft strand, the third graft strand, and the fourthgraft strand of the ACL graft extend out of the tibial tunnel through afirst opening in an outer surface of the tibia; positioning a distal endof a graft strand tensioner against bone around the first opening in theouter surface of the tibia so that a longitudinal axis of the graftstrand tensioner is substantially coaxial with a longitudinal axis ofthe tibial tunnel, the graft strand tensioner including a tensioning armassembly situated proximally of the distal end of the graft strandtensioner, the tensioning arm assembly movable within the graft strandtensioner away from the distal end of the graft strand tensioner alongthe longitudinal axis of the graft strand tensioner, the tensioning armassembly, including a tensioning arm support member that extendstransversely across the longitudinal axis of the grail strand tensioner,the tensioning arm assembly further including a first tensioning armcoupled to a first end of the tensioning arm support member and a secondtensioning arm coupled to a second end of the tensioning arm supportmember; coupling: (i) the first graft strand of the ACL graft to a firstend of the first tensioning arm; (ii) the second graft strand of the ACLgraft to a second end of the first tensioning arm; (iii) the third grailstrand of the ACL graft to a first end of the second tensioning arm;(iv) the fourth graft strand of the ACL graft to a second end of thesecond tensioning arm; and moving the tensioning arm assembly away fromthe distal end of the grail strand tensioner while the distal end of thegraft strand tensioner remains against bone around the first opening inthe outer surface of the tibia, wherein said moving applies respectivetensions to the first graft strand, the second graft strand, the thirdgraft strand, and the fourth graft strand of the ACL graft, and whereinduring said moving: (a) the tensioning arm support member rotates withinthe graft strand tensioner about a support member axis that issubstantially perpendicular to the longitudinal axis of the graft strandtensioner; (b) the first tensioning arm rotates about a first tensioningarm axis that is substantially perpendicular to the support member axis;and (c) the second tensioning arm rotates about a second tensioning armaxis that is substantially perpendicular to the support member axis sothat following said moving the first graft strand, the second graftstrand, the third graft strand, and the fourth graft strand of the ACLgraft are substantially equally tensioned.
 2. The method of claim 1,wherein the ACL graft is an artificial ACL graft.
 3. The method of claim1, wherein the graft strand tensioner maintains a substantially equalamount of tension on the first graft strand, the second graft strand,the third graft strand, and the fourth graft strand of the ACL graftfollowing said moving.
 4. The method of claim 3 further comprisingimplanting a tibial implant in the tibial tunnel through the firstopening in the outer surface of the tibia with the distal end of thegraft strand tensioner remaining against bone around the first openingin the outer surface of the tibia and while maintaining saidsubstantially equal amount of tension on the first graft strand, thesecond graft strand, the third graft strand, and the fourth graft strandof the ACL graft with the graft strand tensioner.
 5. The method of claim4, wherein the tibial implant passes through passage in the distal endof the graft strand tensioner.
 6. The method of claim 3 furthercomprising cycling a knee joint of the patient following said moving,the knee joint including the femur and the tibia.
 7. The method of claim6 further comprising moving the tensioning arm assembly further awayfrom the distal end of the graft strand tensioner following said cyclingand while the distal end of the graft strand tensioner remains againstbone around the first opening in the outer surface of the tibia.
 8. Amethod of placing an ACL graft in a patient, comprising: anchoring anACL graft to a femur of a patient with a first graft strand, a secondgraft strand, a third graft strand, and a fourth graft strand of the ACLgraft extending out of the femur and through an adjacent tibial tunnelin a tibia of the patient so that the first graft strand, the secondgraft strand, the third graft strand, and the fourth graft strand of theACL graft extend out of the tibial tunnel through a first opening in anouter surface of the tibia; positioning a distal end of a graft strandtensioner against bone around the first opening in the outer surface ofthe tibia, the graft strand tensioner including a tensioning assemblysituated proximally of the distal end of the graft strand tensioner, thetensioning assembly movable within the graft strand tensioner away fromthe distal end of the graft strand tensioner along a longitudinal axisof the graft strand tensioner, the tensioning assembly including a firstgraft strand attachment point, a second graft strand attachment point, athird graft strand attachment point, and a fourth graft strandattachment point that are spaced apart from one another within thetensioning assembly so that the first graft strand attachment point, thesecond graft strand attachment point, the third graft strand attachmentpoint, and the fourth graft strand attachment point correspond to afirst quadrant, a second quadrant, a third quadrant, and a fourthquadrant, respectively, positioned around the first opening in the outersurface of the tibia, wherein the tensioning assembly includes: (a) afirst point of rotation located between the first graft strandattachment point and the second graft strand attachment point on a firstreference line connecting the first graft strand attachment point andthe second graft strand attachment point; (b) a second point of rotationlocated between the third graft strand attachment point and the fourthgraft strand attachment point on a second reference line connecting thethird graft strand attachment point and the fourth graft strandattachment point; and (c) a third point of rotation located between thefirst reference line and the second reference line; coupling: (i) thefirst graft strand of the ACL graft to the first graft strand attachmentpoint of the tensioning assembly; (ii) the second graft strand of theACL graft to the second graft strand attachment point of the tensioningassembly; (iii) the third graft strand of the ALL graft to the thirdgraft strand attachment point of the tensioning assembly; (iv) thefourth graft strand of the ACL graft to the fourth graft strandattachment point of the tensioning assembly; and moving the tensioningassembly away from the distal end of the graft strand tensioner whilethe distal end of the graft strand tensioner remains against bone aroundthe first opening in the outer surface of the tibia, wherein said movingapplies respective tensions to the first graft strand, the second graftstrand, the third graft strand, and the fourth graft strand of the ACLgraft, and wherein during said moving rotation occurs within thetensioning assembly at the first point of rotation, the second point ofrotation, and the third point of rotation so that following said movingthe first graft strand, the second graft strand, the third graft strand,and the fourth graft strand of the ACL graft are substantially equallytensioned.
 9. The method of claim 8, wherein said positioningsubstantially aligns the longitudinal axis of the graft strand tensionerwith a longitudinal axis of the tibial tunnel.
 10. The method of claim8, wherein the ACL graft is an artificial ACL graft.
 11. The method ofclaim 8, wherein the graft strand tensioner maintains a substantiallyequal amount of tension on the first graft strand, the second graftstrand, the third graft strand, and the fourth graft strand of the ACLgraft following said moving.
 12. The method of claim 11 furthercomprising implanting a tibial implant in the tibial tunnel through thefirst opening in the outer surface of the tibia with the distal end ofthe graft strand tensioner remaining against bone around the firstopening in the outer surface of the tibia and while maintaining saidsubstantially equal amount of tension on the first graft strand, thesecond graft strand, the third graft strand, and the fourth graft strandof the ALL graft with the graft strand tensioner.
 13. The method ofclaim 12, wherein the tibial implant passes through a passage in thedistal end of the graft strand tensioner.
 14. The method of claim 12,wherein the tibial implant includes four longitudinally extending ribson an exterior surface of the tibial implant, the four longitudinallyextending ribs being laterally spaced apart from one another so as toprovide a first exterior implant quadrant, a second exterior implantquadrant, a third exterior implant quadrant, and a fourth exteriorimplant quadrant around the exterior surface of the tibial implant, andwherein said implanting includes receiving the first graft strand in thefirst exterior implant quadrant, the second graft strand in the secondexterior implant quadrant, the third graft strand in the third exteriorimplant quadrant, and the fourth graft strand in the fourth exteriorimplant quadrant.
 15. The method of claim 11 further comprising cyclinga knee joint of the patient following said moving, the knee jointincluding the femur and the tibia.
 16. The method of claim 15 furthercomprising moving the tensioning assembly further away from the distalend of the graft strand tensioner following said cycling and while thedistal end of the graft strand tensioner remains against bone around thefirst opening in the outer surface of the tibia.
 17. The method of claim8, wherein the third point of rotation occurs along a tensioning armsupport member that extends transversely across a longitudinal axis ofthe graft strand tensioner.
 18. The method of claim 17, wherein thefirst point of rotation occurs along a first tensioning arm coupled to afirst end of the tensioning arm support member and the second point ofrotation occurs along a second tensioning arm coupled to a second end ofthe tensioning arm support member.